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The Mortuary Science Program is located across from Phoenix-Mesa Gateway Airport at
the corner of South Sossaman Road and East Tahoe Avenue. The physical address is 7440
East Tahoe Avenue, Mesa, Arizona 85212. Best cross streets are Ray Road and Power
Road. Take Ray Road east to Sossaman, make a right and go South on Sossaman to Tahoe
Avenue and the building is on the corner.
Mortuary Science Program
Application and General
Information
2016-2017
Location:
Phoenix-Mesa Gateway Center of
Mesa Community College
Phone (480) 988-8501
2
TABLE OF CONTENTS
Information Area Page
MCC Mortuary Science Program Overview and General Information…………………......3-4
Program Aims and Objectives ……………………………………………………………... 5
MCC Mission / Vision / Values ……………………………………………………………..6
Admissions Procedures and Requirements/Proposition 300 Information ……………..... 7-9
Phoenix- Mesa Gateway Center Student Residential Living ………………………………10
Phoenix-Mesa Gateway Center Map ………………………………………………………11
Associate of Applied Science in Mortuary Science………………………………………....12
Application Packet Portion Cover Sheet ……………………………………………………13
Transcript Evaluation Request Form……………………………………………………….14-15
Mortuary Science Disclaimer …………………………………………………………….. 16
Assumption of Risk and Hold Harmless ………………………………………………… 17
Hepatitis Vaccine Requirement ………………………………………………………….. 18
Hepatitis B Vaccine Declination Form …………………………………………………… 19
1st Hepatitis B Vaccine Form …………………………………………………………….. 20
2nd Hepatitis B Vaccine Form …………………………………………………………… 21
3rd Hepatitis B Vaccine Form …………………………………………………………… 22
Mortuary Science Application …………………………………………………………….23-24
Enrollment Information:
Donna G. Backhaus, CFSP
Mesa Community College Mortuary Science
7440 East Tahoe Avenue Mesa, Arizona 85212
Phone (480) 988-8503 Fax (480) 988-8520
APPLICATIONS MUST BE RECEIVED BY JUNE 1
3
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
This information is for applicants to the Mesa Community College Mortuary Science Program
located at the Phoenix-Mesa Gateway Center in Mesa, Arizona. All inquiries for information
and enrollment procedures should be directed to the Mortuary Science Program Mesa
Community College (480).988-8503., 7440 East Tahoe Avenue, Mesa, Arizona 85212 or the
Advisement is available by calling 480-988-8503
The deadline for submitting the application and all supporting documents including
general education and prerequisite transcripts for the fall semester program start is June 1.
A minimum GPA of 2.50 on a 4.00 scale is required for all general education and prerequisite
courses that apply to the Associate of Applied Science degree in Mortuary Science.
Equal-access Opportunity: The Maricopa County Community College District does not
discriminate on the basis of race, color, religion, national origin, sex, sexual orientation,
handicap/disability, age, or Vietnam era/disabled Veteran status in employment or in the
application, admission, participation, access and treatment of persons in instructional programs
and activities.
English as a Second Language: The Maricopa County Community College will take steps to
ensure the lack of English language skills will not be a barrier to admission and participation in
vocational education programs.
Program Accreditation: The Associate of Applied Science (AAS) degree in Mortuary Science
at Mesa Community College is accredited by the American Board of Funeral Service Education,
(ABFSE) 3414 Ashland Avenue, Suite G, St. Joseph, Missouri 64506, Phone (816) 233.3747
Fax (816) 233.3793. The website address is www.abfse.org
Mesa Community College is regionally accredited by the Higher Learning Commission, North
Central Accrediting Agency.
Program Director: Dr. Thomas R. Taggart is a graduate of Worsham College of Mortuary
Science. He is a licensed embalmer and funeral director with more than 50 years of funeral
service experience. His Bachelor of Science degree from Aurora University has a major in
biology and chemistry and a minor in education. His Master of Science degree from Northern
Illinois University is in biochemistry. The Educational Specialist degree he earned at Mississippi
State University is in Vocational Technical Education and his Doctorate from Mississippi State
is in Educational Leadership.
Coordinator of Mortuary Science Program Operations: Donna Backhaus has more than 20
years of experience in funeral service in Arizona. In addition to her Associate in Applied Science
degree in Mortuary Science from MCC, she holds a Bachelor of Science degree in Business
Management and a Master of Arts degree in Education: Adult Education/Distance Learning from
the University of Phoenix.
4
GENERAL INFORMATION
Job Market: Good to Excellent according to National Studies. According to Government
Studies, the Funeral Business is one of those service professions that will never be replaced. On a
National basis, there are more jobs than there are licensed personnel to fill them – you may need
to relocate to get the job, but the jobs are there.
What type of person becomes a Funeral Director: People from all walks of life enter the
funeral service profession; they are everyone – young, old, rich, poor, male or female. Age is a
definite asset in funeral service and many retired police, fire and military personnel become
active members of the funeral profession.
State Requirements: The individual State requirements for entry into the funeral profession
vary from state to state and from as little as a Certificate of Completion to a four year Bachelor
degree.
The minimum credential for graduation from an American Board accredited school is the two
year Associate of Applied Science degree – AAS. This is the degree that MCC offers. If a
student is planning to attend MCC and comes from a state that requires two years of education
plus Mortuary Science, we recommend that the student complete the Associate of General
Studies first, and then with an additional two semesters will complete the AAS degree and be
licensable in all states having such a requirement. The states requiring two years of education
plus Mortuary Science are: New Mexico, Nevada, Idaho, Nebraska, Iowa, Wisconsin, Michigan,
Pennsylvania, Kansas, Montana, New Jersey, North Dakota, Oklahoma and South Dakota.
There are currently two states that require a Bachelor degree, Ohio and Minnesota. If the student
wishes to attain a Bachelor degree, we recommend the student complete our AAS degree and
then transfer to a number of schools with whom MCC has articulation agreements: ASU, ASU
Poly, NAU, Ottawa University, University of Phoenix, Western International University, Grand
Canyon University, etc. This avenue allows the student to obtain an additional skill above the
Mortuary Science degree, such as accounting, psychology or business.
It is appropriate to mention at this point that whether a student receives a one-year certificate, an
associate’s degree or a Bachelor’s degree, the amount of Mortuary Science coursework is the
same. The American Board of Funeral Service Education (ABFSE) has in its required curriculum
52 semester hours of required Mortuary Science course work. The student receiving the 4 year
degree will have no more funeral service education than the student receiving the one-year
certificate. With this in mind, students wanting to obtain a higher degree would want that degree
to be in another related discipline giving that student a more advanced and well-rounded
education with additional skills.
5/15
5
MORTUARY SCIENCE PROGRAM AIMS AND OBJECTIVES
The program has as its central aim the recognition of the importance of funeral service personnel
as:
Members of a human services profession;
Members of the community in which they serve;
Participants in the relationship between bereaved families and those engaged in the
funeral service profession;
Professionals knowledgeable of and compliant with federal, state, provincial/territorial,
and local regulatory guidelines in the geographic areas they practice as well as
Professionals sensitive to the responsibility for public health, safety and welfare in caring
for human remains.
The program has the following objectives:
To enlarge the background and knowledge of students about the funeral service
profession;
To educate students in every phase of funeral service and to help enable them to develop
proficiency and skills necessary for the profession;
To educate students concerning the responsibilities of the funeral service profession to
the community at large;
To emphasize high standards of ethical conduct;
To provide a curriculum at the post-secondary level of instruction; and
To encourage student and faculty research in the field of funeral service.
These aims and purposes adopted from the American Board of Funeral Service Education, 3414
Ashland Avenue, Suite G, St. Joseph, MO 64506. Phone (816) 233.3747, are consistent with and
supportive of those of the Maricopa County Community College District (MCCCD) and Mesa
Community College.
The aims of the Mortuary Science program are communicated through program publications
both to the campus and the wider community to insure that all understand its nature.
5/15
6
MESA COMMUNITY COLLEGE
VISION, MISSION and VALUES
VISION
MCC – leading the way to success in our local and global community
MISSION
MCC excels in teaching, learning and empowering individuals to succeed in our local and global
community. We serve as a resource for college and career readiness, transfer education,
workforce development, and life-long learning.
VALUES
Learning - MCC champions individual student success that reflects the highest academic
standards.
Innovation – MCC delivers cutting edge instruction and service.
Service Excellence – MCC makes a positive difference in the lives of our students, community
members and each other through meaningful relationships.
Integrity – MCC upholds the highest standards of ethics and public stewardship
Individuals and Community – MCC encourages active citizenship and embraces the diversity
of people and ideas.
7
Admission Procedures & Requirements
1. An application for the Mortuary Science Program must be completed in addition
to enrolling as a student at Mesa Community College by establishing a Maricopa Student
ID and account at www.my.maricopa.edu. Application information are available online
at http://www.mesacc.edu/dept/d26/msp/ or at the Mortuary Science building located at
7440 East Tahoe Avenue Mesa, Arizona 85212. Phone (480) 988.8501
2. Completion of all general education courses and prerequisites is required BEFORE the
application date of June 1.
3. General Education and Prerequisite courses need to meet the A.A.S. (Associate of
Applied Science) degree in Mortuary Sciences and must reflect a minimum G.P.A. of
2.50 to be considered for the program. Higher GPA is encouraged.
4. Students are admitted to the program only once, each fall semester. Applications,
official transcripts, and all supporting documents must be submitted the Mortuary
Science Program Office, 7440 East Tahoe Avenue Mesa, Arizona 85212 by June 1st.
An official transcript request form MUST be filled out in order to get the transcript
evaluated. Official transcripts must be mailed TO Mortuary Science Adviser Donna
Backhaus FROM the college or university directly.
5. Applications will be sent to the selection committee ONLY if the file is complete.
A complete file includes the following:
Register at the college and obtain a student ID at my.maricopa,edu
Complete Mortuary Science Application
Official College and/or University transcripts – Complete
transcript evaluation form. Allow sufficient time for transcript
evaluation. Have transcripts mailed directly from the institution to
Mesa Community College Mortuary Science, 7440 East Tahoe
Avenue Mesa, Arizona 85212 Attn: Donna Backhaus prior to the
June 1 deadline.
Official Transcripts from ALL Maricopa Community Colleges
must be requested by the student and sent directly from those
colleges to MCC for general and prerequisite courses and electives.
Official Mortuary Science school transcripts (if applicable)
Proof of immunization/vaccine requirements or Declination Letter
6. It is the responsibility of the applicant to verify completion of their file. Contact
the MCC Mortuary Science Office for verification.
7. Applicants are responsible to maintain their current address and telephone number
and email at the Office of Enrollment Services, Any change in status should be changed
within your my.maricopa.edu student center and reported immediately to your enrollment
adviser
8
RESIDENCY & CITIZENSHIP INFORMATION (PROP 300/HB2008/SB1070)
Please refer to this link: http://www.mesacc.edu/admissions-records/residency-citizenship
The Maricopa Community Colleges have announced the procedures they are using to comply with
Proposition 300.
The College’s efforts to comply with the law mean that students are being asked to provide
information about their citizenship or legal status. To qualify for in-state tuition and financial
assistance, students must provide documentation as proof of residency. Acceptable documents include
a birth certificate, an Arizona driver license or ID card issued August 1, 1996 or later, and official
immigration papers. Students who successfully complete the Federal Free Application for Federal
Student Aid (FAFSA) will not need to show additional proof of citizenship.
Proposition 300, passed by Arizona voters in November 2006, stipulates that college students who are
not legal United States citizens or are without lawful immigration status must pay out-of-state
commission and that persons who are not United States citizens and who are without lawful
immigration status are not eligible for financial assistance using state money. The law requires that
those who are not citizens or legal residents pay out-of-state tuition. The law requires that those who
are not citizens or legal residents pay out-of-state tuition, which now is $325.00 per credit hour for
students taking seven or more credit hours. The in-state tuition rate is $84.00 per credit hour. Tuition
subject to change without notice.
Acceptance Procedures 1. Applicants accepted into the program will receive the following:
a. Either a conditional or an unconditional letter of acceptance. The
conditional letter will stipulate the necessary procedures prior to enrolling.
b. Disclaimer form to be completed and returned prior to enrolling.
c. An Advisement/Registration form with the approved classes for
enrollment.
2. Applicants who are accepted and fail to enroll or pay all necessary fees by the due
date indicated on the billing statement will forfeit acceptance into the program.
General Information 1. There are no dormitory facilities on the MCC main campus. The ASU Polytechnic
Campus/Williams Educational Center offers on-campus housing for students. See attachment
for information, or call (480) 727.1700. Housing and transportation arrangements are the
student’s responsibility.
2. The student shall be responsible for their own transportation to various clinical sites.
3. It is essential that Mortuary Science students be able to perform a number of physical
activities in the clinical/lab portion of the program. At a minimum, students will be required to
lift human bodies, stand several hours at a time, and perform bending activities. The
clinical/lab experience also places students under considerable mental and emotional stress
9
as they undertake responsibilities and duties in embalming human bodies. Individuals
should give careful consideration to the mental and physical demands of this program prior
to making application.
4. Advanced placement of courses must be evaluated on an individual basis.
5. Special fees: MSP 202 - Embalming (1st semester) $500.00; and MSP 207 - Restorative Art
(2nd semester) $500.00.
Tuition: In addition to the special fees, General Tuition for County Resident: $84 per credit hour;
Out-of-State: $325 per credit hour. (Subject to change without notice).
6. With respect to Pre-requisite and General Education Courses:
Course substitutions must be approved prior to the application deadline
The above courses may be transferred from any regionally accredited college or University with
a grade of C or better. Or, they may be completed at any of the 10 Maricopa Community Colleges.
The course MSP 101 – “Orientation to Funeral Service” – is open to any student. Completion of
this course is not a guarantee of admission to the Mortuary Science Program. However, this
course allows students to review the opportunities available should they pursue a career in funeral
service. It is typically offered in the fall semester for three weeks and offered as well in the
evening in the spring semester,
7. The Mortuary Science Program is a total educational experience covering all aspects of
funeral directing, embalming, and funeral home management. This is a block/cohort program,
and the second year of the Associate of Applied Science degree. Your best vehicle to licensure
after graduating from an ABFSE Accredited school is the taking and passing of the National
Board Examination (NBE). Almost every state in the U.S. accepts a passing score on the NBE.
This is because the laws of the various states are quite different as they pertain to the regulation
of the death care industry. Arrangements to take and pay for this exam ($500) offered by the
International Conference of Funeral Service Examining Boards are the responsibility of the
individual student.
“National Board Examination Scores, graduation rates and employment rates for this and other
ABFSE accredited programs are available at www.abfse.org To request a printed copy of this
program’s scores and rates, go to Mesa Community College Mortuary Science Department, 7440
East Tahoe Avenue, Mesa, Arizona 85212, by email at [email protected] or
[email protected] or by telephone 480-988.8501.”
Admission to the Mortuary Science Program is selective.
The candidate must have completed all prerequisite courses and maintained a GPA of 2.50 or
better. Application must be submitted by June 1st of each year for admission in the fall
semester. For answers to specific questions about the Funeral Profession or Mortuary Science
in general, call Dr. Thomas R. Taggart, LELFD or Donna Backhaus, LELFD at
(480) 988.8501.
10
PHOENIX-MESA GATEWAY CENTER
ASU POLYTECHNIC CAMPUS HOUSING AND RESIDENTIAL LIFE
Eligible students: ASU Polytechnic Housing serves students at ASU Polytechnic, Chandler-
Gilbert Community College and Mesa Community College Mortuary Science students.
Residing on campus is more than just having a place to stay: it’s about finding a place to live.
You’ll invest thousands of dollars into your education for tuition, books and fees. As a result of
these investments, you’ll gain a new range of career options after graduation. Living on campus
is a similar sort of investment. The friends you will make, the additional opportunities for
interaction with faculty, the convenience of being walking distance from classes – all contribute
to the value added experience of living on campus. Few choices you make in college can offer
so much in enhancing your college experience as living on campus.
Student status and eligibility to remain in residential living will be verified each academic
semester. To remain eligible for housing, students must be enrolled throughout the term and
must be making consistent progress towards a degree. When a student withdraws or is
withdrawn from a class for any reason, it is the student’s responsibility to inform Polytechnic
Campus Housing. Falling below the six (6) credit minimum could result in termination of the
License agreement.
Housing for single students is provided in two areas. Houses which can be shared by two or
three students are available on the south part of campus.
Housing for students with families is available in two separate villages on campus. Houses
range in size from 2-5 bedrooms and include Internet, cable television and water. Community
playgrounds and picnic/BBQ areas are located in South and North Desert Village. Faculty and
staff at ASU and the Maricopa Community Colleges are also eligible to reside in family
housing.
ASU Polytechnic Housing is located at 5931 S. Sterling Mesa, Arizona 85212 in the student
union annex (enter parking lot from Campus Loop North).
Rates and options are available at:
http://housing.asu.edu/sites/default/files/2015-2016_PolyRates_1.pdf
How do I apply? For more information on all aspects of residential life, eligibility or
applications, please call University Housing at Poly Campus (480 727.1700. Pricing subject to
change. To inquire and apply online, visit:
http://www.studenthousingatpoly.com
11
12
Associate of Applied Science Mortuary Science I. Required courses* (10-11 semester hours) Credits
ACC 107 Bookkeeping Theory and Practice (or ACC 111) (3-4)
BPC 101 Introduction to Microcomputers I (IBM or Macintosh) (1)
GBS 205 Legal, Ethical, & Regulatory Issues in Business (3)
MGT 253 Owning and Operating a Small Business (3)
II. General Studies Requirements* (12 - 15 semester hours)
Credits
ENG 101 First Year Composition (3)
ENG 111 Technical Writing (or ENG 102) (3)
COM 110 Interpersonal Communication (3)
CRE 101 Critical and Evaluative Reading (0-3)
or test exempt NOTE: (If reading exempt, students must make-up the 3 credits
from any subject course level 100 or higher with a grade of “C” or better.
MAT 112 Mathematical Concepts/Applications (or higher) (3) **
(New course substitution for MAT 102 – Please see requisite requirements) **
III. General Education Distribution Requirements* (10 semester hours)
Credits
REL 243 History of World Religions OR ANY APPROVED AAS degree
Humanities Course (3)
PSY 156 Understanding Death and Dying (or PSY 101) (3)
BIO 160 Introduction to Human Anatomy and Physiology (4)
IV. Specialty Courses (32 semester hours) Credits
Fall Courses-
MSP 101 Orientation to Funeral Service (Required) (1)
MSP 201 History & Sociology of Funeral Service (3)
MSP 202 Embalming & Lab (3+1)
MSP 203 Microbiology for Funeral Service (3)
MSP 204 Chemistry for Funeral Service (3)
MSP 205 Mortuary Administration I (Funeral Directing) (3)
Spring Courses-
MSP 206 Mortuary Administration II (Merchandising & Management) (3)
MSP 207 Restorative Art & Lab (3+1)
MSP 208 Legal, Ethical & Regulatory Issues in Funeral Service (3)
MSP 209 Pathology for Funeral Service (3)
MSP 210 Counseling for Funeral Service (2)
MSP 211 Compendium for Funeral Service (2)
Total Semester Credits …………….. (68-70)
Consult the MCC general catalog for degree requirements
*Course substitutions must be approved prior to the application deadline
** Requisites: Prerequisites: A grade of "C" or better in MAT090, or MAT091, or MAT092, or
MAT093, or successful completion of Maricopa modules, or satisfactory score on District placement
exam.
13
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
APPLICATION
2016-2017
SUBMIT ALL REQUIRED PAPERWORK WITH APPLICATION BY
JUNE 1, 2016
SUBMIT COMPLETE APPLICATION PACKET TO:
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
7440 EAST TAHOE AVENUE
MESA, ARIZONA 85212
ATTN: DONNA BACKHAUS
TELEPHONE: (480) 988-8503
FAX: (480) 988-8520
EMAIL: [email protected]
14
COLLEGE TRANSCRIPT EVALUATION
Individuals who have successfully completed courses or credits at another U.S. regionally accredited
university or college need to request evaluation of these courses for the purpose of establishing
equivalency with Mesa Community College. Official Transcripts must be sent directly from the
institution(s) to:
Mesa Community College – Mortuary Science
7440 East Tahoe Avenue
Mesa, Arizona 85212
In order for the transcript to be evaluated and posted to a student account, the student must be
currently enrolled. Go to my.maricopa.edu and set up a student account with enrollment information.
Transcript requests will be processed in order of receipt. Please allow four (4) to six (6) weeks to be
processed.
NOTE: MCC Sister Colleges (CGCC, SCC, PC, RIO, GCC, EMCC etc.) official transcripts
should be requested online through your Student Center and will be posted to your account.
Transfer within the Maricopa system requires active accounts at all the colleges involved.
Special Programs needing your transcripts at MCC:
Nursing; Athletics; Mortuary Science; Fire Science and Dental Hygiene
NOTES:
Transcripts will be held for one (1) year from the date received and then will be destroyed if a
transcript evaluation request has not been received. The transcript evaluation request follows on the
next page.
Requesting college/university transcript evaluations can also be done online. Click link below and
submit information electronically
https://www.mesacc.edu/admissions-records/transferring-course-credits/college-transcript-evaluation
15
16
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
MORTUARY SCIENCE DISCLAIMER
Your admission to Mesa Community College Mortuary Science Program is no guarantee that you will
graduate from the college. Further, graduation from the college is not the criterion for obtaining a license
as an Embalmer/Director. Licensing requirements are the exclusive responsibility of the various State
Boards and you must satisfy those requirements for licensing.
I have read and understand the Mortuary Science Disclaimer.
____________________________________ ________________________
Signature of student Date
This statement will become part of your permanent record.
Please sign and return immediately to:
Mesa Community College
Mortuary Science Program
7440 East Tahoe Avenue
Mesa, AZ 85212
11/15
17
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
ASSUMPTION OF RISK AND HOLD HARMLESS
In the Mortuary Science Program the student may come into contact with hazardous chemicals. The
college will provide adequate instruction on the handling of hazardous chemicals and holds the student
responsible for properly following instructions.
A student in the Mortuary Science Program must participate in lifting heavy cartons and human bodies.
The student certifies that they are in good physical/mental health to participate in heavy lifting.
I have read this disclaimer, hereby assuming all risk and hold harmless the faculty, staff, and
administration of MCCCD.
_____________________________________ ________________________
Signature of student Date
This statement will become part of your permanent record.
Please sign and return immediately to:
Mesa Community College
Mortuary Science Program
7440 East Tahoe Avenue
Mesa, AZ 85212
11/15
18
HEPATITIS VACCINE REQUIREMENT
Documentation of Hepatitis B vaccine immunization series: Mortuary Science students must
have received the final immunization prior to starting in the Mortuary Science Program.
General Information:
Hepatitis B is a viral infection caused by Hepatitis B virus (HBV). Individuals who work in medical
settings are more at risk than others for acquiring this infection. Because of this increased risk, the
Mortuary Science Program requires that students entering their program receive the hepatitis vaccine
as a protective measure. A high percentage (85%-95%) of healthy people who receive two doses of
the vaccine and a later booster achieve high levels of antibody development (ant-HBV) and receive
protection against Hepatitis B. Full immunization requires three doses of vaccine over a six-month
period. The duration of immunity is unknown, and it is recommended the immunization process be on
a ten-year cycle. The incidence of side effects is low; however, pregnant women should check with
their physician before receiving the vaccine.
You may obtain the vaccine series from any of the following agencies. Some agencies may have
payment schedules, and you may wish to check with them regarding their payment policies.
1. The Community Health Services Clinic, located at: 8117 E. Roosevelt, Scottsdale,
AZ. Telephone: (480) 941-9283. The current charge is approx. $50.00 per injection,
which is the lowest cost that we are aware of at this time. Appointments for vaccines
are necessary.
2. Any of the following primary care centers of the Maricopa County Health Service
Department:
a) Mesa Primary Care Center, 59 S. Hibbert, Mesa, AZ.
Telephone: (480) 962-9181
b) Glendale Primary Care Center, 5141 W. Lamar Road, Glendale, AZ.
Telephone: (602) 931-9361
3. A physician of your choice.
You may wish to check for coverage with your health insurance.
19
MARICOPA COMMUNITY COLLEGE DISTRICT
ALLIED HEALTH PROGRAMS
Rev. 3/15 Vaccination Declination
VACCINATION DECLINATION –Exhibit B
(PRINT) Student Name_________________________ Date________________
(Complete the sections that are appropriate for this student.)
Hepatitis B Vaccination Declination
I understand that due to my exposure to blood or other potential infectious materials during the clinical
portion of my allied program, I may be at risk of acquiring Hepatitis B virus (HBV) infection. The
health requirements for the allied health program in which I am enrolled, as described in the Student
Handbook, include the Hepatitis B vaccination series as part of the program’s requirements.
I have been encouraged by the faculty to be vaccinated with Hepatitis B vaccine; however, I decline
the Hepatitis B Vaccination at this time. I understand that by declining this vaccine, I continue to be at
risk of acquiring Hepatitis B, a serious disease.
By signing this form, I agree to assume the risk of a potential exposure to Hepatitis B virus and hold
the Maricopa Community College Allied Health Program as well as all health care facilities I attend as
part of my clinical experiences harmless from liability in the event I contract the Hepatitis B virus.
_________________________________________ ________________________
Student Signature Date
_______________________________________________________________
Faculty Signature Date
1st HEPATITIS B VACCINE REQUIREMENT
MESA COMMUNITY COLLEGE
20
MORTUARY SCIENCE PROGRAM
7440 EAST TAHOE AVENUE
MESA, ARIZONA 85212
______________________________________________________________________________
Last Name First Middle
__________________________________________
Student ID
________________________________________________________________________________
|
1st HEPATITIS IMMUNIZATION: SUGGESTED SCHEDULE:
DUE ON OR BEFORE JANUARY 1 |________________________________________________________________________________
|
| DATE:
|
|________________________________________________________________________________
|
| SIGNATURE OF HEALTH CARE PROVIDER: |
|________________________________________________________________________________
|
| AGENCY:
|
|________________________________________________________________________________
|
| AGENCY ADDRESS:
|
|________________________________________________________________________________
RETURN THIS FORM TO THE MORTUARY SCIENCE OFFICE BY THE DUE DATE
INDICATED.
FAILURE TO DO SO WILL PREVENT ADMISSION TO THE MORTUARY SCIENCE
PROGRAM.
11/15
2nd HEPATITIS B VACCINE REQUIREMENT
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
21
7440 EAST TAHOE AVENUE
MESA, ARIZONA 85212
____________________________________________________________________________
Last Name First Middle
__________________________________________
Student ID
________________________________________________________________________________
|
| 2nd HEPATITIS IMMUNIZATION: SUGGESTED SCHEDULE:
DUE ON OR BEFORE FEBRUARY 1 |________________________________________________________________________________
|
| DATE:
|
|________________________________________________________________________________
|
| SIGNATURE OF HEALTH CARE PROVIDER:
|
|________________________________________________________________________________
|
| AGENCY:
|
|________________________________________________________________________________
|
| AGENCY ADDRESS:
|
|________________________________________________________________________________
RETURN THIS FORM TO THE MORTUARY SCIENCE OFFICE BY THE DUE DATE
INDICATED.
FAILURE TO DO SO WILL PREVENT ADMISSION TO THE MORTUARY SCIENCE
PROGRAM.
11/15
3rd HEPATITIS B VACCINE REQUIREMENT
MESA COMMUNITY COLLEGE
MORTUARY SCIENCE PROGRAM
22
7440 EAST TAHOE AVENUE
MESA, ARIZONA 85212
______________________________________________________________________________
Last Name First Middle
__________________________________________
Student ID
________________________________________________________________________________
|
| 3rd HEPATITIS IMMUNIZATION: SUGGESTED SCHEDULE:
DUE ON OR BEFORE FEBRUARY 1 |________________________________________________________________________________
|
| DATE:
|
|________________________________________________________________________________
|
| SIGNATURE OF HEALTH CARE PROVIDER:
|
|________________________________________________________________________________
|
| AGENCY:
|
|________________________________________________________________________________
|
| AGENCY ADDRESS:
|
|________________________________________________________________________________
RETURN THIS FORM TO THE MORTUARY SCIENCE PROGRAM OFFICE BY THE DUE
DATE INDICATED.
FAILURE TO DO SO WILL PREVENT ADMISSION TO THE MORTUARY SCIENCE
PROGRAM
11/15
MESA COMMUNITY COLLEGE MORTUARY SCIENCE APPLICATION
Application deadline JUNE 1 each academic year
Name
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Last First Middle
Last name other than above (Maiden or Previous Marriage) :
Address:
Number City State Zip
Student ID # : Home Phone:
Work Phone: Email address:
Education Background: Place date, college, semester/yr. completed and grade for course in appropriate
column. For earned credit, ALL courses must reflect 2.5 GPA or better. All transcripts must be
officially sent from your college directly to Mesa Community College, Mortuary Science Department -
7440 East Tahoe Avenue Mesa, Arizona 85212. Fill out a transcript evaluation form to have your
transcript officially evaluated for transfer credit. Include all courses in progress by semester/year
under the appropriate column.
Pre-requisite and General Education Courses
Course Number Course College Semester/Year
completed
Grade
ACC 107 OR 111 Accounting
BIO 160 Introduction to
Anatomy and
Physiology
BPC or CIS Computers
COM 100 OR
110
Communications
CRE 101 Critical Reading
ENG 101 First Year
Composition
ENG 102 OR 111 First Year
Composition
GBS 205 Legal, Ethical, &
Regulatory Issues
in Business
MAT 112 or
Higher level
Mathematical
Concepts and
Applications
MGT 253 Owning and
Operating a Small
Business
PSY 101 OR 156 Psychology
REL 143 or
Humanities
World Religions
MESA COMMUNITY COLLEGE MORTUARY SCIENCE APPLICATION (Cont).
High School Diploma/ GED: Graduation/completion Date:
School
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City: State:
Name /Location of each College where pre-requisite and/or general education was completed:
Name City/State/ Zip Date Attended Sem. Hours Degree
Have you ever attended a Mortuary Science Program? Yes: No:
If so: School name:
Address
City: State: Zip:
Do you hold a current license? Yes: No: License #:
If yes, where issued? State: Year: Active or Inactive:
Have you ever had a Funeral Director/Embalmer license suspended? Yes: No:
Have you ever been released/withdrawn from a Mortuary Science Program? Yes: No:
Have you ever initiated a withdrawal from a Mortuary Science Program? Yes: No:
Have you ever been convicted of a misdemeanor or felony? Yes: No:
If yes to any of the above questions, please identify institution and explain:
Please list any coursework to be completed before entering the Mortuary Science Program.
List college and semester of enrollment (if not registered at MCC, a copy of class schedule is
required).
I certify that the above answers are true, correct and complete:
________________________________________________ Date ________________________
Signature of Student
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“The Maricopa County Community College District is an EEO/AA institution and an equal opportunity employer
of protected veterans and individuals with disabilities.
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